Types of treatment for breast cancer

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1 Types of treatment for breast cancer Useful information for cancer patients Contents This information is about the main treatments used to treat breast cancer. There are sections on The main treatments Your treatment team Stage and grade of your cancer Tests for receptors on cancer cells Surgery and radiotherapy Breast reconstruction Chemotherapy and hormone therapy Switching off the ovaries Biological therapy for breast cancer Predicting how well treatment may work If you can't have surgery Taking notes Second opinions You can view this information in a larger print on our website. The main treatments The treatments used for breast cancer include Surgery Radiotherapy Chemotherapy Hormone therapy Biological treatments You may have a combination of these treatments, depending on your situation. It is impossible to generalise about breast cancer treatment because there are so many different sets of circumstances. Your doctor will take many different factors into account when deciding which treatment is best for you. Some of the factors they consider are The type of breast cancer you have The size of your breast tumour The stage of your breast cancer The grade of your cancer cells Whether you have had your menopause Whether your cancer cells have receptors for particular cancer drugs Your general health If you feel strongly about having or not having a particular treatment, do tell your doctor. There may be other options for you. And if you would prefer a particular type of treatment, but your specialist hasn't suggested it, you can ask them why. Your specialist can explain the reasons to you. Specialised computer programmes can help doctors decide which treatment may be best in your particular case. The programmes contain all the details of trial results for treatments after surgery for early stage breast cancer. Doctors can type in the details of your cancer and then add in different types of treatment, such as chemotherapy or hormonal therapy. The computer tells your doctor how much each treatment reduces the chance of the cancer coming back. The computer programmes also give information about the risk of side effects. One commonly used programme is called Adjuvant! Online and another is called Predict. Types of treatment for breast cancer 01

2 Your treatment team NHS guidelines emphasise that all breast cancer patients should be under the care of a multi disciplinary team. This is a team of health professionals who meet regularly and work together to decide on the best way treatment and care for each patient. The MDT includes Specialist breast cancer surgeons Doctors who specialise in radiotherapy and cancer drug treatment A breast cancer specialist nurse Doctors who are expert in X-rays and scans A pathologist A counsellor or psychologist Stage and grade of your cancer The tests used to diagnose your cancer give information about its stage and grade. Knowing the stage and grade is important for helping the doctors decide which treatments you need. The stage of your breast cancer means how big it is and whether it has spread. Grade means what the cancer cells look like under the microscope. Breast cancers can be Low grade grade 1 (slow growing) Intermediate grade grade 2 High grade grade 3 (faster growing) Low grade cancers tend to grow more slowly than high grade. High grade cancers are more likely to come back after they have first been treated. But the grade can only give a guide to how any individual cancer will behave and individual cancers may behave differently. Tests for receptors on cancer cells Your specialist in the breast clinic or your breast surgeon will send your breast cancer cells for tests to see if they have hormone receptors or biological therapy receptors. They call this receptor status. Oestrogen is a female sex hormone. It stimulates some breast cancers to grow by triggering particular proteins (receptors) in the cancer cells. If your breast cancer cells have oestrogen receptors, the cancer is said to be ER positive. Hormone therapies that can stop oestrogen from stimulating the cells to divide and grow work well for ER positive breast cancers. Your doctor may recommend hormone therapy to shrink a tumour before surgery. More often they will recommend hormone therapy after surgery, to reduce the chance of the cancer coming back. Testing for particular proteins can help to show whether biological therapies may work as a treatment for your breast cancer. For example, the drug trastuzumab (Herceptin) is only likely to work if your breast cancer cells have a lot of Her2 protein. You may see this written as HER2neu or erbb2. Her2 protein is on the cell surface of up to 1 in 4 early breast cancers. Herceptin attaches to the Her2 protein. If your breast cancer cells don't have this protein, Herceptin won't work. Surgery and radiotherapy Most people begin their breast cancer treatment with surgery. There are different types of surgery for breast cancer. Your doctor may offer you a choice about your treatment. Depending on the size and position of the tumour, you may be able to have just the cancerous lump removed with a border of normal breast tissue (a wide local excision or lumpectomy) plus several weeks of radiotherapy to the rest of the breast. Or you may prefer to have the whole breast removed (mastectomy) and perhaps have a breast reconstruction. Types of treatment for breast cancer 02

3 To help you decide, you may want to consider How you feel about having the whole breast removed How you feel about having only part of the breast removed How you feel about having radiotherapy How quickly you want the treatment to be finished How you would cope with travelling to hospital daily for radiotherapy Whether you want to have a breast reconstruction straight away or some months after surgery There are no right and wrong answers to most treatment decisions. Women each feel very differently. Some women want to keep their breast if at all possible, so they choose a lumpectomy (wide local excision) and radiotherapy. Other women feel that once they have breast cancer they would rather have the whole breast removed and they may then have a new breast made. Some women feel strongly that they don't want radiotherapy. Others welcome it if it means keeping their breast. The most important thing is to take time to find out how you feel and make the right decision for you. For some women the position of the cancer within the breast or its size may mean that they don't have a choice of treatment. If the cancer is quite big, or right in the centre of the breast, the only option may be to remove the whole breast. But reconstruction is usually possible. The type and timing of reconstruction may depend on the need for further treatment such as chemotherapy or radiotherapy. Remember that you don't have to make a decision about treatment straight away. You can say to your specialist that you need some time to think over your options. You can then discuss the issues with family or friends, or reflect on your own about how you feel. Before making a decision you can also ask your specialist or breast cancer nurse more questions about the different treatments if you need to. Breast reconstruction Breast reconstruction is an operation to make a new breast shape after having a breast removed. Or it can be an operation to fill in an area where a large lump was removed from the breast. If you have a mastectomy, you can usually choose whether you would like breast reconstruction at the time of the mastectomy or during a later operation (delayed reconstruction). Sometimes there are medical reasons that make it difficult to do a breast reconstruction. Chemotherapy and hormone therapy You may have chemotherapy or hormone therapy before or after your surgery and radiotherapy. Treatment before surgery Cancer treatment before surgery is called neo adjuvant treatment. You may have chemotherapy or hormone therapy before surgery for large tumours or locally advanced breast cancer to try to make the cancer smaller and easier to remove. Chemotherapy or hormone therapy can often help to shrink the cancer in the breast. Hormone therapy is only used if you have oestrogen receptor positive breast cancer. It will usually be obvious how well the treatment is going to work within 6 to 12 weeks of starting it. Treatment after surgery Chemotherapy or hormone therapy after surgery is called adjuvant treatment. It helps to lower the chance of the cancer coming back. The type of treatment you have depends on Whether you have had your menopause Tests on your cancer cells that help to show whether hormone therapy or chemotherapy will work for you The grade of your cancer cells The size of the cancer in the breast and whether it has spread to your lymph nodes Types of treatment for breast cancer 03

4 Current national guidelines for early breast cancer treatment recommend that you should have hormone therapy after surgery if your breast cancer has oestrogen receptors (ER positive). Younger women who are ER positive may have chemotherapy as well as hormone therapy. Women who have a small cancer with a low risk of it coming back might not need to have chemotherapy. It depends on how much the chemotherapy is likely to help and the person's general health. Switching off the ovaries Women who haven't had their menopause before being diagnosed with breast cancer are still producing oestrogen. Oestrogen can stimulate some breast cancer cells to grow. So some treatments aim to stop the ovaries making oestrogen. For some women, chemotherapy treatment will cause a menopause and tamoxifen hormone therapy can lower oestrogen levels. But there are other ways of stopping the ovaries working. This is called ovarian ablation. Ovarian ablation can cause quite intense menopausal symptoms because the oestrogen levels in the body drop very quickly. To stop your ovaries working, you may have Surgery to remove your ovaries Radiotherapy to the ovaries Drug treatment with luteinising hormone blockers Surgery to remove your ovaries Surgery stops the ovaries working permanently and lowers oestrogen levels in the body. Radiotherapy to the ovaries Radiotherapy treatment to the ovaries stops them producing oestrogen. This treatment is very rarely used. Drug treatment with luteinising hormone blockers If you don't want your ovaries to stop working permanently your doctor may offer you drugs called luteinising hormone blockers for 2 to 3 years. These drugs stop the ovaries producing oestrogen. When you stop having the drug, your ovaries should start to work again. But the nearer you are to the age at which you would naturally have the menopause, the more likely it is that these drugs will switch off your ovaries permanently. In most women, periods come back 6 to 12 months after finishing treatment and they will become fertile (able to have children) again. And any menopausal symptoms usually stop soon after the treatment ends. Biological therapy for breast cancer Biological therapy treats cancer using substances that change cell processes. Trastuzumab (Herceptin) is a type of biological therapy for breast cancer. It only works for women who have receptors for Her2 protein on their cancer cells (known as Her2 positive cancer). If you have early Her2 positive breast cancer, Herceptin may help to stop it from coming back. If you have advanced breast cancer, it may help to keep it under control for longer. For breast cancer that has spread, other biological therapies such as lapatinib (Tyverb) or sunitinib (Sutent) can also control or slow the cancer growth. Predicting how well treatment may work Some doctors in the UK use a formula called The Nottingham Prognostic Indicator (NPI) to give them some idea of how well treatment may work for a person with breast cancer and how long the person may live. It is not possible to predict exactly what will happen to each individual person but the index can give a general idea. The NPI is a useful guide but not a guarantee of what will happen. Types of treatment for breast cancer 04

5 The Index looks at 3 factors The size of the cancer Whether the cancer has spread to the lymph nodes (lymph glands) under the arm (and if so, how many nodes are affected) The grade of the cancer The formula is: NPI = (0.2 x tumour diameter in cms) + lymph node stage + tumour grade, where The lymph node stage can be 1 (if there are no nodes affected), 2 (if up to 3 glands are affected) or 3 (if more than 3 glands are affected) The tumour grade is scored as either 1, 2, or 3 The formula gives scores which fall into three bands A score of less than 4 this suggests a good outcome with a high chance of a cure A score of between 4.01 to 5.4 this suggests an intermediate level with a moderate chance of cure A score of more than 5.4 this suggests a lower chance of cure The NPI is based on information from a group of patients treated some time ago and very few of them had treatment after surgery. Treatment results have greatly improved since then. So it may not give as good an outlook (prognosis) as you actually have, if you are having treatment now. If you can't have surgery Some women have health problems that mean they can't have surgery. Some women choose not to have surgery. In this situation, your doctor may recommend treatment with hormone therapy such as tamoxifen, anastrozole (Arimidex) or letrozole (Femara), if your cancer is oestrogen receptor positive. Doctors call this primary endocrine therapy and it is most often used for women over 70 who have health problems. The treatment will not get rid of the breast cancer but can control it for some time. Taking notes When you are first diagnosed, cancer treatment can sometimes seem very complicated. As you can see there are quite a few different ways of treating breast cancer. And it can seem even more confusing if other people you meet are having different treatments. It is important to remember that other people will have different circumstances to you. They may Be older or younger Have a different type of breast cancer Have a different stage of breast cancer Have a cancer with different hormone receptors or biological therapy receptors Don t be afraid to ask your doctor or nurse if something is puzzling you. It can help to take notes when you talk to people about your treatment. Or you can ask to record the conversation so that you don't forget what your doctor or specialist nurse says. If you still don't understand, do ask again. No one will think it strange that you want to ask a lot of questions about your treatment. Second opinions If you don't feel that you are getting the treatment you want or need, you can ask for a second opinion. This means going to see another specialist and asking them what treatment they think you should have. They will need to see all your test results and X-rays. Having a second opinion doesn't usually mean that the new doctor takes over your treatment and care. They discuss with you and your current doctor which is the best treatment approach to take. Most doctors are quite happy to arrange this for you. It takes time to arrange a second opinion and may mean that your treatment is delayed for a while. Types of treatment for breast cancer 05

6 It is worth discussing your current specialists' approach with them first. Once you have heard why they are suggesting particular treatments for you, you may feel that you don't need a second opinion. It is always a good idea to jot down a few questions before you go to the hospital for an appointment with your specialist. It can be difficult to remember everything you want to ask once you get there. Your doctor won t think this strange. These days many patients write their questions down. For more information, visit our website You will find a wide range of detailed, up to date information for people affected by cancer, including a clinical trials database that you can search for trials in the UK. Our information is based on the best current scientific evidence and reviewed regularly by leading clinicians and experts in health and social care. For answers to your questions about cancer call our Cancer Information Nurses on am till 5pm Monday to Friday. Adapted from Cancer Research UK s website in August Cancer Research UK s website is not designed to provide medical advice or professional services and is intended to be for educational use only. The information provided through Cancer Research UK s website and our nurse team is not a substitute for professional care and should not be used for diagnosing or treating a health problem or disease. If you have, or suspect you may have, a health problem you should consult your doctor. Copyright Cancer Research UK Cancer Research UK is a registered charity in England and Wales ( ), Scotland (SC041666) and in the Isle of Man (1103) Types of treatment for breast cancer 06